Nokea
The nurse is aware that which layer is the muscle layer of the heart, which is responsible for the heart's contraction?
- A. endocardium.
- B. pericardium.
- C. mediastinum.
- D. myocardium.
Correct Answer: D
Rationale: The myocardium is the specialized muscle layer that allows the heart to contract.
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The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this as which arrhythmia?
- A. sinus bradycardia.
- B. atrial fibrillation.
- C. sinus tachycardia.
- D. ventricular tachycardia.
Correct Answer: C
Rationale: Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats/min.
What is the transesophageal echocardiogram (TEE) used for?
- A. Detect thrombi before a cardioversion.
- B. Check for cardiac arrhythmias.
- C. Detect the presence of an aneurysm
- D. Measure effectiveness of diuretic therapy.
- E. Locate obstructions in the coronary artery.
Correct Answer: A,C
Rationale: The TEE is used to check for thrombi before cardioversion, and to visualize the presence of an aneurysm.
A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Which is a characteristic signs and symptoms of angina pectoris?
- A. substernal pain that radiates down the left arm.
- B. epigastric pain that radiates to the jaw.
- C. indigestion, nausea, and eructation.
- D. fatigue, shortness of breath, and dyspnea.
Correct Answer: A
Rationale: The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw.
The plan of care for a patient recovering from hip surgery mentions prevention of deep vein thrombosis (DVT). Which aspect of the plan of care addresses this concern?
- A. Massaging the calves of the leg twice daily
- B. Explaining the need for fluid restriction after surgery
- C. Assisting the patient to change positions frequently
- D. Encouraging the patient to take the anti-embolism stockings off at night for better sleep.
Correct Answer: C
Rationale: The plan of care to prevent deep vein thrombosis should mention changing positions, dorsiflexing the feet and rotating ankles every 2 to 4 hours. Massaging the calves of the leg is contraindicated, as the massage could loosen a blood clot. There is no need to restrict fluids. Removing the stockings off at night is not an appropriate intervention, because a DVT could form.
The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having which disorder?
- A. hepatitis A.
- B. indigestion.
- C. urinary infection.
- D. menopausal complications.
Correct Answer: B
Rationale: Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI.